Calculate Well’s score for PE (BOX1) Suspected Pulmonary Embolus Pathway for Adults Eligible Patients must have: Basic bloods (FBC, IP,) ECG CXR Senior decision (consultant/ ST4+) to commence on pathway Exclusions to pathway: Age < 16 years Pregnant (See separate pathway) Haemodynamic instability Calculate Well’s score for PE (BOX1) 0-1.5 2-4 4.5+ Any positive PERC criteria? Age > 50yrs HR > 100bpm O2 sats < 95% Unilateral leg swelling Haemoptysis Trauma or surgery within previous 4 weeks Previous DVT/PE Hormone use e.g. COCP Bleed patient and request D-dimer sPESI = 0 (BOX 2) patients may be transferred to ACC if open prior to result. For patients definitely requiring admission request MAU bed if not already done so Start on LMWH 1mg/kg BD if no C/I sPESI = 0 (BOX 2) and no contradication to discharge (Box 5) sPESI ≥ 1 (BOX 2) or other contradication to discharge (Box 5) Yes Yes D-dimer greater than 500ng/dl or age x 10 (if patient >50 years)? E.g 85 year old = d dimer cut off of 850ng/dl Suitable for outpatient care ACC referral if patient in ED ACC to request imaging (see BOX 4) Give safety net advice Admit under medical team. Do they need escalation to HDU/ ITU? No No PE excluded, consider alternative diagnosis BOX 1 Well’s score for PE Signs and symptoms of DVT 3 PE most likely diagnosis HR > 100 1.5 Immobilisation >3 days or surgery < 4 weeks ago Previous DVT/PE Haemoptysis 1 Malignancy (treatment in last 6 months/ palliative) TOTAL ______ BOX 2 sPESI score Not suitable for outpatient care if ANY of the following: Tachycardia >110bpm Systolic BP <100mmHg SaO2 <90% Age > 80 years Chronic lung or heart disease Cancer (history or active)

BOX 3 Anticoagulation BOX 4 Imaging Patients awaiting imaging should receive anticoagulation while awaiting imaging unless imaging is available immediately or there is a major contraindication to anticoagulation. Enoxaparin 1mg/kg BD if no contraindication (altered dosing in renal impairment, pregnancy and extremes of weight- check BNF/ discuss with pharmacist) Prescribing Advice for all anticoagulation See BNF for drug interactions If the patient is at risk of bleeding the clinician needs to weigh up risk vs. benefit. Could early imaging be obtained to potentially negate need for anticoagulation? BOX 4 Imaging Timing: All patients with suspected PE in whom radiological imaging is required after initial assessment should be imaged within 24 hours. Stable patients assessed out of normal working hours should be imaged on the first available list the following day. Unstable patients should ideally be imaged within 1 hour. Where a patients’ need for imaging is considered urgent, a senior clinician, should discuss the case with the radiologist on call Imaging modality: Age under 50 and no significant co-morbid cardiorespiratory disease with a normal chest radiograph: VQ SPECT scan if available (Not available after hours) Age over 50 or significant co-morbid cardiorespiratory disease, or abnormal chest radiograph: CTPA. Impaired renal function or previous reaction to contrast discuss with radiologist. Box 5 Do not discharge following groups of patients being treated with anticoagulation for suspected pulmonary embolus Active bleeding or risk of major bleeding On full-dose anticoagulation at the time of the suspected PE Severe pain (requiring IV opioids) Other medical comorbidities requiring hospital admission Chronic kidney disease (CKD) stage 4 or 5 or severe liver disease. Heparin induced thrombocytopenia within the last year and where there is no alternative to repeating heparin treatment. Social reasons which may include inability to return home, inadequate care at home, lack of telephone communication or concern over treatment compliance.